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How much of your scratching is due to itch?
In English the two words itching and scratching are often used by everyone - practitioners and patients - as if they mean the same thing. Strictly speaking, an itch is a feeling, and to scratch is an action, but often it is said that someone is "itching" when they are seen scratching, or another person can complain of feeling "scratchy" when they are feeling itchy. For The Combined Approach it is important that this simple problem is clarified from the beginning.
To others, the person with atopic eczema has a very itchy condition, but when they are asked the important question "What percentage of your scratching in the last 24 hours has been due to itch?", the response is usually an unexpected one. First, the person asked can seem surprised at the question, and the answer is not given immediately. During the pause there is some indication of a personal review taking place. The eyebrows can be raised and the eyes look away, with the lips held closely together, as the answer is being prepared. The question has not been asked before. It has not been an issue for consideration, as the assumption, with all concerned, has been that all the scratching is due to itch. Everything that has been done to help has been to reducing itching.
Then comes the answer: "Well, it is difficult to say. I have never been asked that before. But I think it is about fifty-fifty - about half of my scratching has been due to itch". If the person is with a family member, the answer can cause a characteristic response in the listener: the eyebrows are raised, and the mouth silently opened with surprise.
When 50 consecutive patients with atopic eczema were asked this question, the average answer was 60%. This is a characteristic clinical finding with long-term atopic eczema - and seems to distinguish this condition from the many other skin conditions where itching and scratching are part of the picture.
While some scratching is due to itch, an important part is not directly due to itch at all, but is related to circumstances, and mental state. In short, this part of scratching in long-term atopic eczema is due to habit, and needs treating with habit reversal.